Small bowel intussusception secondary from intraluminal high grade epithelioid cell carcinoma of unknown origin with concurrent metastatic renal ...
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Int J Case Rep Images 2019;10:101003Z01TC2019. Chuang et al. 1
www.ijcasereportsandimages.com
CASE REPORT PEER REVIEWED | OPEN ACCESS
Small bowel intussusception secondary from intraluminal
high grade epithelioid cell carcinoma of unknown origin
with concurrent metastatic renal cell cancer
Tzu-Yi (Arron) Chuang, Havish Srinath, Hassan Malik,
Paul Tingey, Raphael Varghese
ABSTRACT Article ID: 101003Z01TC2019
Intussusception is an unusual cause of intestinal
obstruction especially in adult populations. *********
Malignant lesion accounts for approximately 30– doi: 10.5348/101003Z01TC2019CR
35% of small bowel intussusception in the adult
population. We presented here a rare clinical
case of a 66-year-old demented male with small
bowel intussusception from intraluminal tumor INTRODUCTION
of unknown origin with concurrent metastatic
renal cell carcinoma. Intussusception is an unusual cause of intestinal
obstruction, in which accounts for approximately
Keywords: High grade epithelioid carcinoma, 1–5% of bowel obstructions. Intussusception is rare
Intraluminal tumor, Intussusception, Meta- in the adult population, which carries about 5% of all
static renal cell carcinoma cases of intussusceptions [1, 2]. Among of all adult
intussusceptions, malignant lesion accounts for
How to cite this article approximately 30–35% of small bowel intussusception
[2, 3]. The pathophysiology of intussusception secondary
Chuang TY, Srinath H, Malik H, Tingey P, Varghese to tumor (either intraluminal or extraluminal lesion)
R. Small bowel intussusception secondary is associated with alteration of the normal peristaltic
from intraluminal high grade epithelioid cell activity caused by lesions serving as a lead point [2].
carcinoma of unknown origin with concurrent We here presented a rare clinical case of a 66 years old
metastatic renal cell cancer. Int J Case Rep Images demented male with small bowel intussusception from
2019;10:101003Z01TC2019. histologically-demonstrated intraluminal tumor of
unknown origin, with concurrent radiologically-proven
renal cell carcinoma.
Tzu-Yi (Arron) Chuang1, Havish Srinath1, Hassan Malik2,
Paul Tingey3, Raphael Varghese4
Affiliations: 1Surgical Principle House Officer, Department CASE REPORT
of General Surgery, Ipswich Hospital, Ipswich, Queensland,
Australia; 2Surgical Registrar, Department of General Sur- A 66-year-old cachectic male with history of dementia
gery, Ipswich Hospital, Ipswich, Queensland, Australia; 3Sur-
was initially brought in to emergency department with
gical Intern, Department of General Surgery, Ipswich Hospi-
tal, Ipswich, Queensland, Australia; 4General and Colorectal nausea and vomiting and abdomen distension. His past
Surgical Consultant, Department of General Surgery, Ip- medical history included Korsakoff dementia secondary to
swich Hospital, Ipswich, Queensland, Australia. alcohol abuse, malnutrition, vitamin D deficiency and iron
Corresponding Author: Tzu-Yi (Arron) Chuang, 7/141 Sta-
deficiency. Initially, he was admitted under the medical
tion Road, Sunnybank, Queensland 4109, Australia; Email: team as gastroeneteritis. His blood test result revealed
Thomas0227@hotmail.com that he had normal electrolyte balance with potassium of
4.8 (3.5–5.2 mmol/L), sodium of 135 (135–145 mmol/L),
Chloride of 95 (95–110 mmol/L); normal kidney function
Received: 18 November 2018 with creatinine of 78 (64–108 umol/L) and eGFR of 89
Accepted: 17 January 2019 (>60 ml/min/1.73 m2); haemoglobin of 119 (135–180g/L);
Published: 15 February 2019 and white cell count of 14.9 (4.0–11.0x109/L). His urine is
International Journal of Case Reports and Images, Vol. 10, 2019. ISSN: 0976-3198
Int J Case Rep Images 2019;10:101003Z01TC2019. Chuang et al. 2
www.ijcasereportsandimages.com
clear with 10 leukocytes, 10 erythrocytes and 10 epithelial
cells, suggesting no sign of urinary infection. As symptoms
progressed, a CT abdomen/pelvis was conducted which
demonstrated small bowel intussusception at left hemi-
abdomen with the impression of a mass within the lead
point (Figure 1). There was also an incidental finding
suggestive of right renal cell carcinoma invading the right
renal vein and probable right adrenal and right lower
lobe pulmonary nodule metastasis (Figure 2). During
admission, the patient had spontaneously resolved his
Figure 2(A and B): Right renal mass with radiological proven
intussusception and was discharged back to care facility renal cell cancer.
with plan of outpatient follow up. Patient returned to the
emergency department a few days later with worsening of
symptoms. Repeated CT abdomen/pelvis again revealed
recurrent intussusception in the right iliac fossa. He was
admitted under general surgery and a nasogastric tube
and in dwelling urinary catheter were inserted. His bowel
obstruction had intermittently resolved and reoccurred.
Decision of palliative intention surgery was discussed
with his next of kin for the purpose of resolving his acute
surgical problem. Optimisation of his cachectic status
was planned prior to his surgery (pre-operative albumin
of 27 g/L). Total parenteral nutrition was initiated with
daily electrolyte check to avoid refeeding syndrome. His
operation occurred on the nineteenth day of his second
admission.
Laparoscopy was initially conducted and mid small
Figure 3: (A) (Left) Small bowel intussusception from the mass
bowel intussusception with dilated proximal bowel and
(B) (Right) The intraluminal mass post-enterotomy.
collapsed distal bowel was identified. It was deemed to
be high risk to reduce intussusception laparoscopically.
Therefore, small right sided Lanz incision was made to
deliver small bowel. A large palpable mass was found at
the proximal side of intussusception (Figure 3A and B). A
longitudinal enterotomy was made and a 60x38x40 mm
intra-luminal polypoid and lobular tumor was resected
by pedunculated stapled approach (Figure 4). A limited
resection of small bowel where tumor was attached was
performed. The primary anastomosis as functional end-
to-end was conducted with PROXIMATE linear cutters
Figure 1: Intussusception at left abdomen causing small bowel Figure 4: Staple resection of intraluminal mass with appropriate
obstruction (yellow arrow). This picture also demonstrated margin.
right renal mass.
International Journal of Case Reports and Images, Vol. 10, 2019. ISSN: 0976-3198
Int J Case Rep Images 2019;10:101003Z01TC2019. Chuang et al. 3
www.ijcasereportsandimages.com
(TLC) 75 mm stapler and oversewn with 3–0 PDS. Distal of 2–5% of small bowel metastatic melanoma deposit
enterotomy was closed transversely with 3–0 PDS. Small in patients with malignant melanoma of the skin [6].
bowel was then carefully examined again via laparoscopy Renal cell carcinomas constitute 7.1% of cancers that
approach. No mesenteric deposits or other deposits of metastasize to the small intestine. Other forms of
tumor were noted. cancer that commonly metastasize to the small intestine
He was closely observed in intensive care unit one include lung, cancers of the head and neck, breast,
day post-operation. He recovered uneventfully from the and oesophagus [2]. Intraluminal metastases usually
surgery. However, he had a prolonged hospital admission presented with gastrointestinal bleeding due to tumor
with urinary tract infection and slow recovery. During invasion to intestinal vessels, and some may present with
admission, a CT abdomen/pelvis was repeated 2 weeks obstructive symptoms or perforation [5, 7–9].
post-surgery for ongoing abdominal pain. It was found In our case, the exact primary of intraluminal carcinoma
that the metastatic lesion at the right lung base has was unable to be identified. This has complicated the
significantly increased in size from 1.5 to 4.2 cm in 1 diagnostic dilemma and delayed potential treatment as
month, and there was also enlargement of his right renal immunohistochemistry tests required a long time for
mass. results.
Post-operative histology of the intraluminal tumor Few potential origins of his small bowel tumor
was unfortunately non-specific. The histology testing were proposed. Firstly, his radiological proven primary
demonstrated that the tumor is high grade epithelioid right renal cancer metastasized to small bowel, right
malignancy of unknown origin. Its morphological adrenal and right chest. Secondly, primary lung cancer
features are not typical of a renal cell carcinoma or metastasized to small bowel, right kidney, right adrenal
a primary small intestinal adenocarcinoma. Further and right chest. Thirdly, small bowel tumor is the primary
immunohistochemistry had been performed. cancer which metastasis to right kidney, right adrenal
The neoplastic cells stain with SALL4 (typically positive and right chest. Finally, there were synchronous primary
in germ cell tumors), CDX2 (focally positive in carcinoma tumors.
of colorectal origin), cytokeratin markers AE1/AE3 and These theories had all been shown by previous case
CK8/18, markers for CK7, CK20, S100m, PAX8, GATA3, reports. Numerous case reports had demonstrated renal
Hep Par1, TTF1, CD34, chromogranin, synaptophysin, cell carcinoma can metastasize to small bowel causing
MUM1, inhibin, desmin, and Melan-A were all negative. intussusceptions [1–3, 5, 7].
All negative immunohistochemistry results have left the Dilege et al. [8] had published a case report of
diagnosis of tumor’s origin undetermined. an adult intestine intussusception from epithelioid
His case was discussed in colorectal multidisciplinary type mesenchymeal tumor (gastrointestinal stromal
team meeting. As there was no definitive diagnosis of tumors, also known as GISTs) as primary tumor of the
metastatic renal cell carcinoma, we were unable to offer small intestine. GISTs are a heterogeneous groups of
palliative chemotherapy. Given his interval progression mesenchymal tumors which arise from the gastrointestinal
of metastatic cancer and poor prognosis, palliative tract. The small intestine is the second most common site
approach with possible palliative radiation therapy was of GISTs. Guner et al. [10] also had published a case report
offered with agreement of patient’s next of kin. Patient to demonstrate metastasized sarcomatoid carcinoma of
was subsequently discharged from hospital back to care the lung to cause intestinal obstruction. However, none
facility on day 36 of his admission. of these immunohistochemistry results were consistent
with our histology report.
Based on the clinical picture, the idea of metastatic
DISCUSSION primary renal carcinoma metastasize to small bowel is
more favorable. Unfortunately, no formal pathological
Intussusception in adults is a rare cause of intestinal diagnose of RCC was able to be performed as patient
obstruction. It is often difficult to diagnose as it has diverse and his family declined kidney biopsy when palliation
presentations and varied symptoms. Radiological studies treatment was offered.
had been found to be useful in preoperative diagnosis, It was recommended that the mainstay of this
including abdominal ultrasound, plain abdominal films, condition is surgical resection of lesions to reduce
upper gastrointestinal contrast series, barium enema or intussusceptions as it not only gives symptoms relief but
CT abdomen/pelvis. Abdominal CT has been considered also potentially improves survival benefit [2, 5].
as the most useful tool to diagnose intussusception with a
reported accuracy of 58–100% [4]
It is extremely rare that intussusception is caused CONCLUSION
by intraluminal tumor. It was noted that small bowel
tumors are more common from secondary cancer than Intussusception caused by intraluminal polypoid small
primary and they occur equally in jejunum and ileum bowel tumor from metastatic cancer is extremely rare.
[5]. Melanomas are the most common form of cancer The exact pathophysiological of intraluminal polypoid
to metastasise to the small bowel. There is an incidence tumor from metastatic cancer is uncertain. Surgical
International Journal of Case Reports and Images, Vol. 10, 2019. ISSN: 0976-3198
Int J Case Rep Images 2019;10:101003Z01TC2019. Chuang et al. 4
www.ijcasereportsandimages.com
intervention of complete excision is recommended by and interpretation of data, Drafting the article, Revising
authors not only for palliative symptoms relief but also it critically for important intellectual content, Final
potentially survival benefit. approval of the version to be published
Havish Srinath – Substantial contributions to
conception and design, Acquisition of data, Analysis
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2012;2012:962683. Copyright
© 2019 Tzu-Yi (Arron) Chuang et al. This article is
********* distributed under the terms of Creative Commons
Attribution License which permits unrestricted use,
Acknowledgements distribution and reproduction in any medium provided
We would like to thank emergency, pathology, urology, the original author(s) and original publisher are properly
medical oncology and palliative department colleagues’ credited. Please see the copyright policy on the journal
contribution in this patient’s care. website for more information.
Author Contributions
Tzu-Yi (Arron) Chuang – Substantial contributions to
conception and design, Acquisition of data, Analysis
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